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Established Status Epilepticus – Second-Line Treatment — SCE Neurology MCQ

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EasyEpilepsy & Seizure DisordersEstablished Status Epilepticus – Second-Line TreatmentSCE Neurology

A 42-year-old woman with epilepsy presents to the emergency department having been found seizing by paramedics. She has received two doses of buccal midazolam in the community and one dose of IV lorazepam on arrival. Seizures continue 25 minutes after the first benzodiazepine. Per NICE NG217, which second-line agent should be given next?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: E — IV phenytoin or IV levetiracetam

Explanation lettering: C = shown as A · E = shown as B · A = shown as C · B = shown as E

Per NICE NG217, if seizures persist after adequate first-line benzodiazepine treatment, second-line options include IV phenytoin (or fosphenytoin), IV levetiracetam, or IV sodium valproate. These should be given as a loading dose in established status epilepticus. The choice depends on the patient's current medications and comorbidities. A: A third dose of benzodiazepine risks respiratory depression without additional benefit. C/D: Thiopental and propofol are third-line agents for refractory SE requiring ICU. E: Rectal paraldehyde is used in paediatric protocols.

Reference: NICE NG217 (2025)